Conference Coverage

How to use transgastric necrosectomy for midline pancreatitis



– When pancreatitis symptoms don’t resolve within a month, patients need some sort of surgical intervention, according to Steven Hughes, MD, FACS, professor and chief of surgical oncology at the University of Florida, Gainesville.

Dr. Steven Hughes

Pancreatitis management has been evolving in recent years. Prophylactic antibiotics and total parenteral nutrition are out; tube feeds are in, and there’s compelling evidence to take the gallbladder out, regardless of etiology, he said at the annual clinical congress of the American College of Surgeons.

However, too many patients get drains placed in the first 2 weeks; it’s the wrong move because it consigns to surgery a lot of patients who otherwise would have recovered on their own. “In the first 2 weeks, please do not place drains. Once you place the drain, you have committed the patient to a very different clinical course,” Dr. Hughes said.

Surgery generally comes a month or more after the initial presentation. Infection is inevitable at that point; the delay gives the lesion time to consolidate and wall itself off, making for a cleaner, safer operation.

Transgastric necrosectomy is the go-to when pancreatic lesions are toward the midline. It’s Dr. Hughes’s favored approach when the anatomy is appropriate; he shared his thoughts at the meeting.

Transgastric necrosectomy provides “single-stop shopping. You can get a thorough debridement in a single procedure,” and durable internal drainage. “Most importantly, from a patient’s perspective, it leaves them without external drains. You can transition a patient who’s been percutaneously drained to no external drainage at the time of this operation,” he said.

Additional pluses include cholecystectomy either before or after necrosectomy and the ability to place enteric feeding systems. “I like to use a combination G-J tube that allows drainage of the emptying stomach along with distal tube feeds,” he said.

Laparoscopic and endoscopic approaches are possible, but Dr. Hughes favors an open procedure “because the finger is the best debriding tool I have found.” There’s an anterior and then posterior gastric incision to dig out the necroma. The anterior incision is closed, but the posterior cut is sealed open to the necroma with a running hemostatic suture to allow for a “large cavity between the cavity and the stomach” for ongoing drainage.

“I have ultrasound on the field, but typically finding the necroma is like falling out of a canoe and finding water.” Even so, “I like to bring a 10-mm straight scope for direct viewing onto the field to explore the necrotic cavity and ensure I’ve done an adequate necrosectomy,” he said.

“I do think that this operation can be performed in patients who have some retrocolic extension even over into the pancreatic head and down the right paracolic gutter, but certainly if the collection extends down towards the pelvis, the notion that this is going to be adequate in and of itself requires further investigation,” he said.

In a cohort of 18 patients he and his colleagues followed for at least 2 years, “I was impressed that this operation is rather durable,” with rapid resolution of disease, Dr. Hughes said. Just a couple people needed additional operations. “The majority created persistent fistulas between the pancreatic body tail and the stomach.”

He cautioned that the procedure “is not for the faint of heart. The splenic vein and the splenic artery as well the celiac axis and portal vein are at risk during this procedure, and if you get into them, you have got a wolf by both ears. I would encourage you to consider referral for these patients.”

Dr. Hughes strongly encouraged surgeons to “ make sure your interventional radiologists and advanced endoscopists are on board, whether for the postop pseudoaneurysm bleeding or recurrent sepsis.”

Dr. Hughes had no relevant disclosures to report.

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